2024 MIPS Measure #498: Connection to Community Service Provider

Quality ID 498
High Priority Measure Yes
Specifications Registry
Measure Type Process
Specialty Allergy/Immunology Audiology Cardiology Certified Nurse Midwife Chiropractic Medicine Clinical Social Work Dermatology Emergency Medicine Endocrinology Family Medicine Gastroenterology General Surgery Geriatrics Infectious Disease Internal Medicine Interventional Radiology Mental/Behavioral Health Nephrology Neurology Neurosurgery Nutrition/Dietician Obstetrics/Gynecology Oncology/Hematology Ophthalmology Orthopedic Surgery Otolaryngology Pediatrics Physical Medicine Physical Therapy/Occupational Therapy Plastic Surgery Podiatry Preventive Medicine Pulmonology Rheumatology Skilled Nursing Facility Speech/Language Pathology Thoracic Surgery Urgent Care Urology Vascular Surgery

Measure Description

Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.



This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for patients who are screened for HRSNs. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Include only patients that have been seen during the denominator identification period of November 1st of the previous performance period through October 31st of the current performance period. This will allow the evaluation of at least 60 days after the denominator eligible encounter within the performance period.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.



Patients aged 18 years or older who screened positive for at least one of the five HRSN domains (food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety) during the measurement period


Community Service Provider (CSP) – Defined as any independent, for-profit, non-profit, state, territorial, or local agency capable of addressing core or supplemental health-related social needs. The clinician’s own organization may be considered a CSP for the purposes of the measure (e.g., a clinic with an in-house food pantry or co-located housing resources).

Denominator Identification Period – The period in which eligible patients can have a denominator eligible encounter. The “denominator identification period” occurs from November 1st of the previous performance period thru October 31st of the current performance period. This will allow for a full 12- month period for denominator eligibility determination.

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged 18 years or older


Patient encounter during the denominator identification period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99421, 99422, 99423, 99441, 99442, 99443, G0402, G0438, G0439


Patients who screened positive for at least 1 of the 5 HRSNs: M1320



Patients who are counseled on connection with a CSP and explicitly opt out: M1317



Patients who had contact with a CSP for at least one of their HRSNs within 60 days after screening


Contact – For the purpose of reporting this measure, defined as engagement with CSP for the purpose of addressing at least one HRSN, either as reported by patient or acknowledged from CSP.

NUMERATOR NOTE: Electronic health record and non-electronic clinical data, as well as patient reported data and electronic data received from CSP may be used to determine whether contact was made with a CSP.

Numerator Options:

Performance Met: Patients who had documented contact with a CSP for at least one of their screened positive HRSNs within 60 days after screening (M1319)


Performance Not Met: Patients who did not have documented contact with a CSP for at least one of their screened positive HRSNs within 60 days after screening OR documentation that there was no contact with a CSP (M1318)



In its 2022 Strategic plan, CMS placed screening for and acting on health-related social needs as a key goal underpinning its strategic health equity pillar [1]. In particular, HHS Secretary Becerra has noted the importance of collecting more robust DOH data to address the disparities [2,3] exposed by COVID-19 and leveraging the data and experience from the CMMI Accountable Health Community (AHC) model, which has screened over one million beneficiaries [4]. CMS has also recognized the importance of making DOH measures standard across programs, identifying the development and implementation of “measures that reflect social and economic determinants” as a key priority and measurement gap to be addressed through Meaningful Measures 2.0 [5]. Healthcare experts have increasingly recognized that equity is unachievable without addressing Social Drivers of Health (SDOH) [6], calling for CMS to require program “participants to uniformly screen for and document drivers of health” and “build [S]DOH measures into MIPS and all APMs” [7]. Likewise, physicians and other providers have called on CMS to create standard patient-level SDOH measures – beyond socioeconomic status (SES), hierarchical condition category (HCC) score, or dual-eligible status – recognizing that these risk factors transcend specific subpopulations [8]; associate with poorer health outcomes [9]; drive demand for healthcare services [10]; escalate physician burnout [11]; and penalize physicians caring for those patients via worse Merit-based Incentive Payment System (MIPS) scores [12, 13].

Along with existing SDOH screening measures, understanding the nature and frequency of patient connection to community resources provides valuable insight into efforts to address SDOH across sectors and in communities. This measure leverages data and experience from OCHIN’s nationwide network of Community Health Centers, who as of January 2023 had documented over 1.6 million SDOH screens in the EHR, as well as CMMI’s 5+ years of data and experience with the Accountable Health Communities (AHC) program [14, 15], which measured screening, referral, and navigation across over 1.1 million beneficiaries.


1. Centers for Medicare & Medicaid Services. CMS Strategic Plan Pillar: Health Equity. 2022. https://www.cms.gov/sites/default/files/2022-04/Health%20Equity%20Pillar%20Fact%20Sheet_1.pdf. Accessed September 2022.

2. Hake M, Dewey A, Engelhard E et al. “The Impact of the Coronavirus on Food Insecurity in 2020 & 2021.” National Projections Brief, March 2021. Feeding America. https://www.feedingamerica.org/sites/default/files/2021-03/National%20Projections%20Brief_3.9.2021_0.pdf. Accessed September 2022.

3. Center on Budget and Policy Priorities. “The COVID-19 Economy’s Effects on Food, Housing, and Employment Hardships.” Special Series: COVID Hardship Watch, February 2022. https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-recessions-effects-on-foodhousing-and. Accessed September 2022.

4. Senate Finance Committee. Finance Committee Hearing for Xavier Becerra, Nominee for HHS Secretary, February 2021. https://www.finance.senate.gov/download/responses-to-questions-for-the-record-to-thehonorable-xavier-becerra. Accessed September 2022.

5. Centers for Medicare & Medicaid Services. “Meaningful Measures 2.0: Moving from Measure Reduction to Modernization.” CMS.gov, 2022. https://www.cms.gov/meaningful-measures-20-moving-measure-reductionmodernization. Accessed September 2022.

6. Navathe A, Emanuel E, Glied S, et al. "Medicare Payment Reform’s Next Decade: A Strategic Plan For The Center For Medicare And Medicaid Innovation." Health Affairs Blog, December 18, 2020. https://www.healthaffairs.org/do/10.1377/hblog20201216.672904/full/. Accessed September 2022.

7. Dutton M, Ellis K, Perla R, Onie R. Investing in Health: A Federal Action Plan. January 2021. Manatt Health/The Health Initiative. https://blueshieldcafoundation.org/sites/default/files/publications/downloadable/Investing%20in%20Health%20 -%20A%20Federal%20Action%20Plan%20-January%202021_Final.pdf. Accessed September 2022.

8. Berkowitz SA, Hulberg AC, Standish S, et al. “Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management.” JAMA Internal Medicine, vol. 177, no.2, 2017, pp. 244-252.

9. Gold R, Kaufmann J, Gottlieb LM, et al. “Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes.” American Journal of Preventive Medicine, vol. 63, no. 3, 2022, pp. 392-402.

10. The Physicians Foundation. 2020 Survey Of America’s Physicians: Covid-19 Impact Edition. October 2020. https://physiciansfoundation.org/wp-content/uploads/2020/10/2020-Physicians-Foundation-Survey-Part3.pdf. Accessed September 2022.

11. De Marchis E, Knox M, Hessler D, et al. “Physician Burnout and Higher Clinic Capacity to Address Patients' Social Needs.” Journal of the American Board of Family Medicine, vol. 32, no. 1, 2019, pp. 69-78.

12. The Physicians Foundation. Open Comment Submission: Response to the Medicare Program CY 2021 Quality Payment Program Proposed Rules. October 2020. https://physiciansfoundation.org/wpcontent/uploads/2020/11/PF-QPP-Open-Comment-Submission-v.f_-.pdf. Accessed September 2022.

13. Khullar D, Schpero WL, Bond AM, et al. “Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System.” JAMA, vol. 324, no. 10, pp. 975-983.

14. Centers for Medicare & Medicaid Services. “Accountable Health Communities Model.” CMS.gov, 2021. https://innovation.cms.gov/innovation-models/ahcm. Accessed September 2022.

15. Johnson KA, Barolin N, Ogbue C, Verlander, K. ”Lessons From Five Years Of The CMS Accountable Health Communities Model." Health Affairs Forefront, August 2022. https://www.healthaffairs.org/content/forefront/lessons-five-years-cms-accountable-health-communitiesmodel. Accessed September 2022.


Clinical Recommendation Statements

The USPSTF provides a “B” recommendation that recommends that clinicians screen for Intimate Partner Violence (one of the HRSNs included in the denominator of the proposed measure) in women of reproductive age and provide or refer women who screen positive to ongoing support services [1]. They cite adequate evidence that available screening instruments can identify IPV in women, and that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit.

In addition to this individual measure, USPSTF has also released a technical brief on screening and interventions for social risk factors [2] which notes that social risk factors are mentioned in two-thirds of USPSTF recommendation statements, and six other professional medical organizations explicitly promote clinician engagement in social risk screening and referrals. The report also highlights the lack of unintended consequences encountered during implementation of social risk screening and intervention in studies reporting these outcomes, despite any perceived barriers.


1. United States Preventive Services Task Force. Final Recommendation Statement: Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening. October 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuseof-elderly-and-vulnerable-adults-screening. Accessed September 2022.

2. Eder M, Henninger M, Durbin S, et al. Screening and Interventions for Social Risk Factors: A Technical Brief to Support the U.S. Preventive Services Task Force. September 2021. Agency for Healthcare Research and Quality. https://uspreventiveservicestaskforce.org/uspstf/sites/default/files/inlinefiles/Social%20Risk%20Factors%20Tech%20Brief_Assembled%20for%20Web_Sep%202021_1.pdf. Accessed September 2022.

Register with MDinteractive